Do Not Resuscitate Orders (DNR): The Continued Dilemma Alan Sanders, PhD Director, Ethics, CHE Trinity Health August 6, 2014

Question 1 An 80 yo F with HTN, hypothyroidism with a DNR comes to the ED c/o dizziness, SOB, and rapidly deteriorating (unstable) condition. She is unable to talk to you. Cardiac monitoring reveals SVT. Should you: A.Cardiovert her. B.Do not perform any electrical shocks, even if this results in her death. C.Not enough information. © 2014 Catholic Health East / Trinity Health2

Question 2 A 68 yo F with asthma and metastatic breast cancer with a DNR comes in with an asthma exacerbation triggered by an accidental exposure to a cat. She has impending respiratory failure. Should you: A.Intubate her. B.Do not intubate her, even if this results in her death. C.Not enough information. © 2014 Catholic Health East / Trinity Health3

Question 3 A 75 yo M with severe COPD (FEV1 0.7) with a DNR comes in with a COPD exacerbation and has impending respiratory failure. Should you: A.Intubate him. B.Do not intubate him, even if this results in his death. C.Note enough information. © 2014 Catholic Health East / Trinity Health4

The Fundamental Issue? o From New Jersey POLST form, but representative of most, if not all states regarding the meaning of DNR © 2014 Catholic Health East / Trinity Health5

What Does DNR mean? o Only applies to basic CPR o Does not apply to all ACLS protocols o Does not have a shared meaning across RHM’s “code teams”, “rapid response teams”, etc. o Does not mean “Do-not-treat” o Does not address treating pre-arrest conditions (e.g. temporary ventilation for a DNAR patient who can be successfully treated for respiratory insufficiency) 6© 2014 Catholic Health East / Trinity Health

Pre-arrest period Pre-arrest period may include failing heart and/or ineffective breathing; and may lead to cardiac or respiratory arrest if management fails Pre-arrest period scenarios include managing dysrhythmias, ventilatory insufficiency, ineffective gas exchange, respiratory failure Use of ACLS protocols is not limited to cardiac and respiratory arrest situations; they are also used in the management of pre-arrest conditions and adverse clinical events. © 2014 Catholic Health East / Trinity Health7

DNR & Advance Care Planning o DNR/AND is very limited in the context of comprehensive advance care planning, especially in the acute care setting o DNR/AND discussion often used as a substitute for advance care planning o In the acute care setting, DNR/AND can serve as a “ceiling” for patients/families pushing for overly aggressive treatment © 2014 Catholic Health East / Trinity Health8

CHE Legacy o Case o Woman with a DNI only (not DNR) o What does the DNI mean? o A wish to not live long term on ventilation? o What about short term for respiratory insufficiency? o Computerized Practitioner Order Entry (CPOE) o Standardization forced the ethical issue to be addressed 9 © 2014 Catholic Health East / Trinity Health

CHE Legacy Changes New choices will be: Full Resuscitation DNAR (No Resuscitation) DNAR (and Other Limitations) DNAR (Comfort Measures Only) 10 © 2014 Catholic Health East / Trinity Health

CHE Legacy cont. 3. DNAR (and Other Limitations) Do not resuscitate in the event of cardiac and respiratory arrest and ‘Do Not Provide’ the following therapies in a pre-arrest situation(allow multiple selections) o Artificial Ventilation o Intubation o IV Vasoactive Agents o IV AntiArrhythmic Agents o Cardioversion o Defibrillation o Blood or Blood Products 11 © 2014 Catholic Health East / Trinity Health

Trinity Legacy 12© 2014 Catholic Health East / Trinity Health Full Resuscitation Provide all therapy to prevent cardiac or respiratory arrest. DNAR No CPR efforts if cardiac or respiratory occurs. Provide all other therapies to prevent cardiac or respiratory arrest. DNAR and Do Not Provide the Following Therapies Next slide DNAR Comfort Measures Only

Trinity Legacy cont. 13© 2014 Catholic Health East / Trinity Health

Other Health Systems o Level I – Full treatment, including CPR o Level II – Selected Limitations, no CPR and: o No Endotracheal Intubation o No Mechanical Ventilation o No Pacemaker Insertion o No Dialysis o No Electrical Defibrillation o No Invasive Monitoring o No Blood Products o No Vasopressors o No Inotropic drugs o Level III – Comfort measures only 14© 2014 Catholic Health East / Trinity Health

Continued Questions o Goal of CPOE o Communication in a crisis? o More thorough advance care planning? o Affects which options appear, where, how, to whom o Meaning of code status o Differs across institutions o Some have pre-arrest code teams o Continued struggle for healthcare professionals o Interpretation, application, “re-training” o Communication of complex orders o Outside of acute care? o EMT’s and out-of-hospital DNR orders 15© 2014 Catholic Health East / Trinity Health